Objective: To review emotional intelligence (EI) literature in the context of how its application can help mediate various stressors among medical students, physicians-in-training, and faculty. Also, discussed are potential barriers to why EI-based programs face challenges to full implementation in medical education.Literature Search: MEDLINE, PsychINFO, EMBASE, Google Scholar, and Web of Science were searched for English language articles using various combinations of the following terms: EI, medical students, medical education, graduate medical education, trainees (including intern, resident, and residency), practitioners, and physicians. Electronic publications and printed books referenced by primary sources were also included.Results: Although there is increasing evidence for EI implementation being favorably associated with physician wellness, decreasing burnout, building better physician-patient relationships, and even better patient outcomes, there has so far not been a large scale movement to integrate EI into medical school curricula. The main barriers to wider implementation of EI are general lack of awareness, insufficient time and resources, and paucity of qualified faculty.Conclusions: Despite a number of associated potential benefits, EI has been facing various implementation hurdles in the medical education setting. Increasing awareness of EI and its benefits could help medical schools and residency programs around the globe to more actively engage in the implementation of EI training into medical school and residency curricula. We expect that such interventions would have several desirable outcomes, including improved overall physician wellness, enhanced patient experience, and perhaps even improved patient outcomes.The following core competencies are addressed in this article: Practice-based Learning and Improvement, Patient care, Professionalism, Interpersonal and communication skills, Systems-based practice.

Medical education places significant demands on trainees and may be associated with substantial stressors. For trainees, these may trigger undue amounts of stress and anxiety, leading to burnout and depression.[1] Major stressors include the immense academic workload and inherently competitive training environment (e.g., class ranking, exam scores, competitive clinical rotation placement, etc.) that can result in tremendous academic and social pressures on medical trainees. In addition, the transition from classroom to clinical learning environments is an additional stressor. The clinical learning environment requires self-care, self-management, social awareness, and social skills — capacities that students often neglect to develop in favor of “book learning.” These new attributes suddenly become crucial to leading functional, healthy, and balanced lives. Beyond this, the trainee's clinical learning environment is characterized by constant change. The trainee must be able to adapt rapidly to professional interactions with new people, seamlessly transition between subject areas and various healthcare environments, with all these demanding changes occurring on a monthly or bi-monthly cycle.[2],[3] In some countries, including Canada, the United States, the United Kingdom, and New Zealand, rising costs of medical education lead some trainees to take on increasing amounts of debt, which can itself be a significant stressor and lead to adverse effects on student performance, feelings of callousness (e.g., lack of empathy) toward others, and the delay of positive life events.[4],[5],[6],[7]

As a consequence, practitioners (including trainees) may find themselves caught in a cycle of self-neglect, resulting in declining dietary habits, lack of physical exercise, outright inability to generate “quality” personal time, and for those with families, decreased amount of time spent with loved ones and friends (e.g., work-life imbalance).[8],[9] The lack of self-care, in turn, may lead to gradual deterioration in mental health, resulting in phenomena such as burnout and not infrequently considerations of abandoning the medical training and the profession altogether.[10] In one study, medical students demonstrated a significant decrease in exercise and socialization, accompanied by an increase in alcohol consumption and depressive symptoms during their 1st year of medical education.[11] Nearly half of medical students may experience some degree of burnout and approximately 10% report suicidal ideation.[12] In another study, 12% of the students were found to have probable major depression and nearly 10% mild-to-moderate depression.[13] Approximately 11% of the medical students have seriously considered dropping out of medical school.[14]

As medical students transition to residency, many fail to recognize the demands, and potential stressors, entailed in such multi-year, intense training regimen. Moreover, the hope that “things will get better” is often met with the reality of “things getting worse” as trainees realize that not only does residency require more academic commitment; their patient care duties and responsibilities may actually increase as they advance.[15] While there are differences in medical education from country to country, stress and burnout have been reported in trainees around the globe.[16],[17],[18] Such disconnect with reality may lead to unanticipated sequelae. In one study, residents reporting burnout were more likely to make medication errors than those who did not feel burned out.[19] Another study found that physician burnout was associated with lower patient satisfaction and longer postdischarge recovery time.[20] Finally, a more recent study found that emotional exhaustion of residents was associated with mortality among patients in the intensive care unit.[21] For these and many other reasons, physician trainee's well-being appears to be vital for patient outcomes and the overall quality of medical care and, therefore, should be a major topic of concern for the medical community.

The psychological concept of emotional intelligence (EI) [Figure 1] and [Table 1] has been proposed as both a predictor of, and as a substrate for, improving both one's well-being and work performance. This has been demonstrated in several professional contexts, perhaps most notably in the field of business.[22] In medicine, EI is positively correlated with physician job satisfaction and resilience against burnout [23] and is postulated to play a role in patient satisfaction, though the last point is somewhat controversial.[24],[25] The importance of continues to be explored in medicine [26] and in related fields such as dentistry,[27],[28],[29] with emphasis on EI's relationship to practitioner stress levels, clinical performance, and job satisfaction. For example, in dental undergraduates, low EI scores correlated with greater amounts of perceived stress.[30] At the same time, higher EI scores are correlated with better ability to reflect and appraise, as well as social and interpersonal, and organizational/time-management skills.[28] EI instrument has been shown to reliably measure desirable personal and interpersonal skills in medical school applicants, suggesting that EI should be included among selection criteria by Admission Committees.[31],[32] Chew et al. demonstrated that medical students who had higher EI scores on the objectively measured Mayer-Salovey-Caruso EI Test performed better in continuous assessments and the final aggregate professional examination.[33] For applicants to an Emergency Medicine residency, EI instrument was shown to measure desirable applicant qualities not captured by academic performance or faculty interviews.[34] It has also been noted that EI measures correlate well with the competencies outlined by the American Council for Graduate Medical Education (ACGME) for postgraduates. Specifically, correlations were shown both with competencies that might be expected to require EI, such as interpersonal and communication skills, and with competencies for which the applications of EI are less obvious, such as practice-based learning and improvement.[35] In the posttraining period, physician EI has been correlated loosely with patient satisfaction.[23],[24] Key domains of EI are outlined in [Table 2a]. Components of the Emotional Quotient inventory are presented in [Table 2b].

Figure 1: Emotional intelligence (EQ or EI) is an essential part of the whole individual, and dynamically interacts with traditional concept of intelligence (IQ) and social intelligence (SQ or SI). The latter is a reflection of one's ability to effectively interact/function within an organization or a group

Despite increasing amount of research demonstrating the benefits of EI for physicians and evidence showing that EI may be developed via dedicated training, barriers exist that continue to hinder awareness and prevent EI from becoming widely acknowledged and implemented as an important component of medical training. For example, a recently published review concluded that EI training in medical education might be beneficial to teaching professionalism and communication skills, but more research was needed due to methodological challenges related to measuring EI.[36] In the current article, the authors propose that coping skills required to succeed in medical school, residency training, and in professional practice can be bolstered by increasing the awareness of, and providing training in, EI and related topic areas. Here, we review the principles of EI, its known benefits and shortcomings, barriers to implementation, and inclusion of EI in the current medical education paradigm, as well as other ideas for future consideration and investigation.

What is emotional intelligence?

The concept of EI first arose in the 1930s and was termed “social” or “nonintellectual intelligence”. The term “EI” was coined and formally defined by Salovey and Mayer in the 1990s as “…A type of social intelligence that involves the ability to monitor one's own and others' emotions, to discriminate among them, and to use this information to guide one's thinking and actions.”;[37] They further expanded this definition to include “the verbal and nonverbal appraisal and expression of emotion, the regulation of emotion in the self and other(s), and the utilization of emotional content in problem solving.”[37] It should be noted that there are currently several theories of EI.[22],[38],[39] Goleman's framework is grounded in the context of the workplace and explicitly addresses work performance. Because the clinical learning environment of medical trainees is essentially similar to a workplace of practicing physicians and allied healthcare professionals, and because of our interest in EI in the work performance of medical trainees, here we will explore EI through Goleman's four key domains of self-awareness, self-management, social awareness, and relationship management [Table 1] and [Table 2].[22] All theories of EI propose that it may be learned and developed. Thus, we may include findings grounded in other theories as we describe how each domain can be targeted during interventions to enhance the well-being and professional performance of students, trainees, and physicians.

Self-awareness

The most fundamental principle behind EI is increasing self-awareness through mindfulness, or “...paying attention in a particular way, on purpose, in the present moment and nonjudgmentally...”[40] Applying mindfulness allows people to pause, “notice” their thoughts and emotions, recover from “distractions” more effectively, increase appreciation for everyday activities, and gain emotional stability.[41] The art of practicing mindfulness is facilitated by employing meditation, or the “...family of mental training practices that are designed to familiarize the practitioner with specific types of mental processes....”[42] Meditation trains attention and meta-attention or the ability to pay attention to “the attention itself” (e.g., the understanding of factors which influence the level of attention of an individual). People learn to pay attention to thoughts, sensations, perceptions, and emotions as temporary physiologic experiences that can be observed calmly without becoming “caught up” and controlled by them. A healthy emotional self-awareness allows maintenance of a calm, but alert state.

Emotional self-awareness is invaluable for physicians. In one study with residents, maladaptive coping strategies such as denial, disengagement, and inappropriate humor correlated with higher degrees of emotional exhaustion and depersonalization.[43] Mindfulness training in such context would serve to provide more balanced, healthier, and nonavoidant coping mechanisms. Another recent study found that mindfulness and self-compassion were positively associated with greater resilience to emotional exhaustion among residents in pediatric and combined medicine-pediatric training programs.[44]

Mindfulness-based stress reduction (MBSR) is a method that includes sitting meditation, body scan meditation, and 7 sessions of Hatha Yoga for 2.5 h each. MBSR training has been shown to reduce stress and adverse stress-related outcomes in people experiencing various life stressors.[40] There is emerging evidence that one mechanism mediating MBSR's effects may be modulation of certain neural pathways, specifically those involved in processing stressors and stress reactions (e.g., those connecting the amygdala and subgenual anterior cingulate cortex).[45] Premedical and medical students reported reduced distress, depression, anxiety, as well as increased empathy, and spirituality after MBSR interventions.[46] In collaboration with the Center for Mind-Body medicine, 15 medical schools offered Mind-Body skills groups to students in an effort to help with self-awareness and other “self-reflection” skills. Such activities are usually based on small group interactions with each group meeting usually for about 2 h a week for 4–12 weeks. Students reported that they were happy to have a safe place to express themselves. They reported reduced anxiety, depression, insomnia, headache, competition with peers, and gained insight into the importance of self-care.[47] Another type of therapy to increase self-awareness is biofeedback training. One study with primary care physicians found that biofeedback training decreased avoidant coping methods and increased more positive coping methods. Participants sought more social support and even reported decreased family stressors.[48]

In EI paradigm, self-awareness depends heavily on accurate self-assessment. A balanced person must be able to be honest about their own strengths and weaknesses, be clear about their own priorities and goals, and be comfortable with who they are as an individual. When these components come together, the person can achieve a state of self-confidence.[41] In other words, external confidence stems from internal confidence, self-acceptance, and “internal peace.”

The ability to perform an honest and accurate self-assessment is an important skill for medical students and physicians-in-training who are continually adjusting to new challenges and changing realities of rapidly revolving clinical rotations. Both students and residents must balance their pride in what they have been able to achieve with the recognition and acknowledgment of their limitations, including what they do not know and when to seek help from those with more experience. Accurate self-assessment is explicitly required for the ACGME competency of practice-based learning and improvement. In one study, an attitude of self-blame was associated with propensity for emotional exhaustion, while a healthy sense of personal accomplishment appeared to be protective from emotional exhaustion and depersonalization.[43]

Traditionally, medical trainees receive most feedback on their performance from those senior to them. Thus, trainees' self-assessments may be biased from their reliance on feedback from one particular point-of-view (e.g., that of an attending physician). In terms of providing useful, well-rounded feedback to incorporate into one's self-assessment (and thus, self-awareness) information, one intervention that has been shown to be beneficial is 360° anonymous feedback, where the individual being evaluated obtains anonymous feedback from the entire interdisciplinary healthcare team, including all professional levels of team membership.[49] When receiving and incorporating feedback, medical trainees should be coached to accept such constructive criticism as an opportunity to improve, and not as personal attacks on their confidence, skills, or competencies.[50],[51] An inability to accept and/or cope with poor performance scores or feedback can lead to further deterioration in self-confidence and when coupled with poor coping mechanisms or low EI, can quickly escalate to burnout, depression, alcohol/substance abuse, and the entry into the hopelessness-helplessness cycle.[52],[53]

Self-management

Self-management involves the application of emotional self-control, trustworthiness, conscientiousness, adaptability, achievement orientation, and initiative.[22] A majority of medical students and residents enter training with a strong achievement orientation, high conscientiousness, and strong initiative. Current admissions processes, residency matching procedures, and the many exams along the way already select for those individuals. Consequently, the subsequent discussion will focus on emotional self-control, trustworthiness, and adaptability.

Emotional self-control can be described as one's ability to cope with negative or otherwise disruptive feelings (e.g., the ability to self-direct and behave professionally in situ ations where nonprofessional engagement may be sought by a third party). There is a frequent tendency to blame external factors for one's misfortunes, failures, and shortcomings. This, in turn, may result in a person's inability to control and/or stop the cycle of self-reinforcing negativity, unfavorable emotions, and/or unfair self-judgments. The mind can be conditioned to immediately let go of these thoughts by continuous training in mindfulness. Mindful people gain time to notice, reflect on, and then choose how to respond in these heated situations.[41]

Emotional self-control is crucial to maintaining professionalism in the workplace. In one study, the authors identified the negative consequences of disruptive behavior by surgeons in the operating room including shifting focus away from the patient, increase in errors, diminished respect for the process and team members, feelings of powerlessness, interrupted learning, and decreased willingness to get help from staff.[54] The foundational component to emotional regulation is emotional self-awareness and the emerging concept of meta-cognition (e.g., “thinking about thinking” discussed toward the end of this manuscript). These skills, in turn, may be developed through the various mindfulness interventions mentioned previously.

Trustworthiness is the willingness of people to be open about their intentions and admitting their shortcomings to preserve their integrity. The presence of trust is essential for high-quality, long-lasting professional relationships between physicians and colleagues, students, patients, families, and other healthcare team members. Conduct such as misrepresenting facts to cover up a mistake or documenting false information could lead to medical errors, and not admitting to (and correcting) the errors can lead to patient harm. Evidence shows that physicians often experience significant professional and personal disruption following medical errors.[55],[56] Therefore, maintaining integrity is important for the physician, the patient, and the work environment.

Adaptability is an important characteristic that is developed gradually through one's experience in hospitals and clinics during the 3rd and the 4th year of medical school and in residency. However, this can also be addressed through simulation-based training. In one study of otolaryngology residents, after undergoing an intervention consisting of high-stress/high-risk simulations with attending physician supervision, 97% of the residents reported that they enjoyed the training and could apply what they learned to real practice. Participants showed improvement in EI scores in a pattern of linear growth across all 4 years of residency. The total department EI score increased from average range to high average, and there was a corresponding increase in patient satisfaction scores (from 85%–90% to 92–99%, respectively).[57] In summary, emotional self-control, trustworthiness, and adaptability are all critical to maintaining a professional environment for compassionate and effective patient care.

Social awareness

Social awareness includes the subdomains of service orientation, organizational awareness, and empathy. In practical terms, altruistic beliefs about providing care to underserved communities and volunteering at a clinic in an underserved area were both associated with better mental health in medical students.[1] Community service by medical trainees is often viewed through the lens of the overall benefit provided to community members. Service learning is emerging as an important complement to the traditional training curriculum, both for that reason and for the important benefits it provides to trainees, including opportunities for critical reflection (e.g., developing self-awareness through self-assessment) and developing cultural competency, an important aspect of social awareness.[58]

The authors of this manuscript propose that organizational awareness tends to be relatively poor among medical students and trainees.[59],[60],[61],[62] Improving organizational awareness among medical students presents a unique challenge as medical school is designed to introduce students to the broad range of clinical settings, and this is currently accomplished by encouraging experience in different hospital systems and clinical learning environments. Further, some medical schools may not be able to accommodate all clinical training at a single hospital complex or clinic. Consequently, prior to entry into the clinical years of medical education, more information on hospital structure, finances, and management, either in general, or focused on the major affiliate(s) of the school, would not only be helpful to the students intellectually but also may increase EI through increased organizational awareness.

Empathy is the ability to experience and understand what others feel while maintaining a clear discernment about one's own feelings and perspectives.[41] It has become an increasing focus in medical education and formalized testing, though without significant validity, and is being increasingly used to evaluate students for selection for medical schools.[63] This is because empathy has also been found to correlate with clinical competence of medical students.[64] In several studies, it was found that physician empathy was associated with long-term patient satisfaction and better health outcomes.[23],[65] In studies involving diabetic patients, physicians with higher empathy scores were found to have fewer acute metabolic complications and lower HbA1c levels among patients under their direct care.[66],[67]

A longitudinal study of medical students' empathy found that a decline in empathy levels may actually be occurring during the 3rd year of medical school and that such trend persisted until graduation.[68] A systematic review of interventions aimed to cultivate physician empathy shows an approximate 80% efficacy of directed education. About 30% of the interventions consist of communication skills-based training, and the remainder included a mixture of role-playing, motivational interviewing, and perspective writing.[63] One study found that a simple exercise consisting of writing about a personal health struggle or a close family member's health struggle increased empathy in students.[69] Students who participated in a program aimed at fostering EI through didactic sessions on communication skills and patient-centered care, and through shadowing in a community-based clinical mentoring program, reported a newfound feeling of responsibility to educate, empower, and develop good physician-patient interactions as a result of the program. In addition, these students reported that they were making connections between EI, leadership, and patient-centered care.[70] Social and structural barriers to care and internal reflections of oneself as an emerging practitioner are among the most challenging perceptual shifts during medical training.[71] Simulations of medical consultations requiring the presence of empathy may also serve as a way to discuss issues such as the doctor-patient relationship with peers and attending physicians while improving student empathy.[72]

Relationship management

Finally, more advanced social skills such as inspirational leadership, influence, teamwork, and conflict resolution are all within the EI skill subset that is highly relevant to medical care. Mentorship is very important in these areas, mainly because these are advanced skills that usually require substantial previous experience. Mentors who demonstrate compassion, a mental state endowed with sense of concern for suffering of others, and aspiration to see that suffering is relieved, are much more likely to gain the trust and respect of their students. “I feel what you are feeling, I understand what you are thinking, and I genuinely want to help…” is the message that typically comes across from a truly compassionate leader. A perceived genuine interest from a leader inspires students to work harder and accomplish more by building self-confidence.[41] Wider implementation of EI training will help foster the development of more attending physicians who strive to be good role models, so that students can be inspired to become compassionate, well-adjusted physicians. This, in turn, will generate a feed-forward cycle of “positive reinforcement” that will benefit all parties involved — students, trainees, attending, and patients.[73],[74],[75],[76],[77]

One study examined aspects of team interactions involving medical students and found that there was a significant relationship between EI and quality of team interactions.[78] Communication skills intervention programs are most helpful when students play active roles practicing skills on simulated or real patients, gaining feedback, and reflecting in small group discussions.[79] In another study, EI scores of 213 dental students were split into two groups, designated as higher EI and lower EI. Follow-up interviews with participants demonstrated that students with higher EI had a more pronounced tendency to use their support networks to cope with stress when compared to the group with lower EI. The authors also suggested that it was important to track and train students in EI because their academic performance may be linked to the ability to cope with stress.[28] Others reported on 28 internal medicine residents, whose EI scores significantly increased over the course of a year. In this pre/post design study, higher scores on EI assessments were related to higher ratings in clinical performance and medical interviewing, as well as lower burnout levels. The authors proposed that the training program's weekly behavioral medicine seminar and monthly support group meetings may have contributed to the observed improvement.[80]

The keys to successful conflict resolution include a combination of all EI skills described so far. Commonly suggested approaches include the 7-step model and principle-based models that stress openness of communication, calm attitude, and flexibility during negotiation,[81] all of which require excellent self-awareness, self-control, empathy, and communication. [Table 3] outlines typical characteristics of individuals with low versus high EI, focusing on typical leadership, communication, and management patterns.

By now, it should be clear that there is evidence supporting how important EI skills are to physicians. The question then becomes, what is preventing further incorporation of EI skills training in medical education? The following section will outline, point-by-point, key components of why EI training should, but is not yet incorporated into the medical curricula around the globe.

Lack of awareness of emotional intelligence

Although various precursor forms of EI have been around for quite some time, it has only been about 25 years old since Salovey and Mayer coined the term and about 20 years since the concept was introduced to the business world and found its way into the mainstream.[37] Consequently, EI is still a fairly new idea in medicine, and although convincing evidence about the benefits of EI skills training has been published, especially in the past decade, the very awareness about key concepts and their definitions is still lacking. Unfortunately, this may be true in the medical community more so than in many other areas providing professional services (e.g. law, education, business), and it has even been postulated that medical education may actually erode some of the desirable attributes that are intended to be taught during the 4 years of professional schooling.[31],[82],[83] Much of the popularized literature has been targeted more toward the general business community. In 2012, Google implemented EI training in a program called “Search Inside Yourself,”[41] and there are numerous publications and Internet-based materials designed to provide targeted education for business leaders, but there has been no great push to popularize EI to physicians on a similar scale.

However, the ACGME and the American Board of Medical Specialties identified a new set of six core competencies in 1999: (a) medical knowledge, (b) patient care, (c) practice-based learning and improvement, (d) professionalism, (e) systems based practice, and (f) interpersonal/communication skills, all of which were shown to have some direct or indirect link to the fundamental EI skillset.[35] Patient care and practice-based learning and improvement require accurate self-awareness and self-assessment; professionalism requires emotional regulation, trustworthiness, and empathy; systems-based practice requires organizational awareness, teamwork, and conflict resolution; and interpersonal/communication skills clearly require social awareness and relationship management skills. There is even some evidence that medical knowledge correlates with EI, though that point is controversial, as some studies included in the meta-analysis by Arora et al.[35] found no association. Based on these criteria, it seems reasonable that the governing bodies of the medical world are beginning to move beyond the simple awareness of the importance of EI skills among physicians, but this has not yet spread to the “mainstream” practicing physician.

Lack of resources (time and funding) to spend on emotional intelligence

One way to more seamlessly incorporate EI into the fabric of the medical profession is through engaging trainees early, during their initial medical school experiences. Having said that, since physicians in practice and residents work such long hours, it seems difficult at first glance to build dedicate more time for EI skills training. However, some of the interventions that have been proven to provide long-term benefits take only between 8 and 24 h to complete. In one study, the intervention of high-risk/high-stress simulations only required 8 h of off-site training, but the effects of the training lasted all 4 years of residency.[57] Another mindfulness intervention in primary care physicians took 18 h during 1 weekend, but again the benefits of intervention lasted a full 9 months.[84] MBSR only requires a total of 17.5 h,[85] and 15 min a day with a biofeedback device for 1 month may be enough to provide lasting benefits.[48]

There should be active incentives to incorporate EI training into medical education and continuing medical education (CME), since physician wellness (as outlined above) correlates with many favorable trends. Enhanced self-awareness and self-regulation by practitioners may lead to fewer medical errors and less litigation. Better social awareness and relationship management skills may result in better outcomes and improved patient satisfaction, more preventative care, fewer costly (and repeated) hospital stays for acute events. Cumulatively, in terms of both time and money, EI training seems to provide a good return on investment.[86],[87],[88],[89]

Lack of teachers for emotional intelligence training

There is a critical need for training and development of “leaders for leaders” within the medical community. Many of those who are successful professionally are gifted with some innate EI skills despite a lack of EI training in their own education. However, even these individuals may not be specifically aware of these talents, or, more likely, how to teach them to others effectively, beyond leading by example. Some may even be unwilling to share the “secrets” of their success with others. After all, excellent EI skills do constitute a clear competitive leadership advantage, and medical education (and practice) is a competitive environment. This paradigm must change. We anticipate that more widespread implementation of EI training at the levels of medical school and residency training will increase the pipeline of attending physicians who can serve as EI teachers. In the future, we also hope that the healthcare and EI/mindfulness communities can come together to provide each other with education and support so that more professionals from both fields can be trained in healthcare-related mindfulness interventions.

Metacognition Exploration and Application in Clinical Education

The concept of metacognition has been introduced in earlier sections of this manuscript and warrants a brief description at this juncture. Since the late 1970s, the term “metacognition” and its function in humans have been studied with increasing recognition within academic, scientific, and professional communities. What is metacognition? The literature identifies several broad definitions of the term. The most general and widely recognized explanation of the word describes it as the ability to understand our “thinking about thinking.”[90] In brief, one could understand metacognition as “…the awareness and understanding of one's own thought processes…” or “…higher-order thinking that enables understanding, analysis, and control of one's cognitive processes, especially when engaged in learning.”[91]

The topic of metacognition in clinical education is receiving more interest in the literature. Falcone et al.[92] studied medical school students' ability to successfully interact during various simulated patient encounters. In one example, students were assigned the task of discussing various stages of care delivery (e.g., discharge planning or continuing care) with the patient, with specific focus on maintaining the patient's feeling of comfort.[92] Investigators hypothesized that senior students would have a higher skill level when communicating with “difficult patients” than junior students. The study findings revealed both groups were successful in communicating with patients, but junior students were less confident in their self-rated performance when compared to the senior group. Senior students were more likely to attribute their success to their grade level or experience.[92]

Lajoie highlights important differences between various schools of thought in the area of metacognition.[93] In brief, some authors believe that awareness of metacognitive functioning comes from within oneself, while others maintain that pertinent triggering is dependent on external cues that humans perceive. The sentiment that is the plurality of opinions in this dynamically evolving area has resulted in major definitional differences and perceived lack of clarity.[94] Lajoie further explores the impact of technology, as applied in the medical education setting, in relation to the awareness of the skills elicited by a medical instructor in a simulation lab.[93] Engagement in such simulated medical setting offers a model for medical students to apply judgment skills and for the instructor to understand student thinking patterns.[93]

An important perspective on the historical application of cognitive research in education is offered by Shunk.[94] More specifically, he emphasizes that greater methodological and research clarity is needed when approaching metacognition, self-regulation, and self-regulated learning. The author also calls for future research efforts that are grounded in strong theoretical and methodological foundations in order to decrease the existing definitional confusion and to encourage synergistic approaches.[94] Moreover, research must focus on exploring potential cause-and-effect relationships and increasing standardization across assessments currently being used, as well as any outcome-based explanations.[94] Finally, although dedicated specialty publications, such as metacognition and learning,[95] help bridge existing gaps, more efforts are needed moving forward. This is especially true when extrapolating general research in metacognition to more complex learning and professional environments such as medical education, residency training, and clinical practice. A summary of metacognitive strategies of successful students and trainees is provided in [Table 4].

Another possible intervention to improve one's self-assessment, and to better cope with stress, is coaching. Coaching can be defined as a “helping relationship” that involves partnering with one in a constructive, thought-provoking, and purposeful process. Major purposes of coaching are the improvement of one's self-awareness and individual performance. Also, coaching helps one clarify values and connect back to the personal/professional purpose that can easily become lost in the busy lives of modern professionals. In the business world, coaches are most frequently used for developing capabilities of the so-called “high-potential” individuals; facilitating transitions (e.g., “in” or “up”); acting as sounding board on organizational dynamics and/or strategic matters; enhancing the interaction of a team, unit, or department; as well as providing leadership, professional, and personal development.[96] In healthcare, coaching may be a way to avoid physician burnout, chiefly because it helps one increase the “internal sense of control” over their situation.[97] For example, a recent randomized clinical study, which examined several characteristics of group coaching intervention, demonstrated that such interventions help increase empowerment and engagement, reduce burnout and symptoms of depression, and enhance the quality of life and job satisfaction.[98] In another study, EI scores of 14 faculty and 16 residents were compared to satisfaction scores of 232 patients. Although correlations between physicians' EI scores and patient satisfaction scores were tenuous, the subscale of “happiness” was associated with patients' level of satisfaction. The authors suggested that physician satisfaction does relate to patient satisfaction and that enrolling physicians in formal coaching process could be a good “ first step” to help address this important relationship while simultaneously curbing the more obvious negative impact of physician burnout on patient experience.[24] Lastly, an effective coach can derive many benefits from the act of coaching that curbs stress and burnout. For example, coaches engage clients through the active listening process. This important coaching skill has been shown to correlate with compassion among coaches, thus helping them to cope better with their own stresses and sustain their effectiveness.[99] Based on this evidence, medical education might consider including coaching and 360° anonymous feedback in their curricula to increase the EI of students, house staff, and faculty.

Future directions

The stress and emotional toll of both training and work in the medical field are much heavier than other workplaces, and there should be some level of advanced education that prepares the physician-in-training for effectively dealing with this aspect of the profession. With increased awareness, the medical education community may become more willing to devote resources for EI training of students and residents. In addition to those interventions we have highlighted in this review, some potential ideas that include interviewing medical school and residency applicants for EI competencies, 1-day EI immersion programs during the orientation of every medical school class and residency program, continuing medical education (CME) retreats focusing on EI as a way to expose more physicians to mindfulness, self-awareness, and biofeedback, and providing EI courses as electives during the 4th year of medical school, before residency, and as an acceptable use of available elective time during residency.

Better understanding of EI dynamics is also needed, so that programs and interventions may be tailored to address individual differences and needs. This is especially true in the context of individual responses under highly stressful situations. For example, there is evidence to suggest that although medical students with higher EI may be more likely to experience significant stress during unfamiliar surgical scenarios, the postevent recovery appears to be better among the high EI group when compared to the lower EI peers.[100] There is also evidence to suggest significant differences in EI domains and skillsets between residents from different specialties.[101],[102],[103] Finally, the continued evolution and inclusion of the concept and the field of metacognition will help address some of the gaps currently present within emotional intelligence and related topics.[95]

Conclusions

Although there is support for EI being favorably associated with physician and physician trainee wellness, decreasing burnout, improved physician-patient relationships, and perhaps better patient outcomes, the integration of EI into medical school curricula continues to be inadequate. Key barriers to wider implementation of EI include insufficient awareness, lack of time and/or financial resources, and paucity of qualified faculty. Consequently, efforts must be supported that help increase awareness of EI as well as its benefits in the settings of medical education and residency training. Such efforts should not be limited to any particular locality or region, but rather should be global in nature. We anticipate that the outcome of these concerted efforts will be improved overall medical trainee and practitioner wellness, enhanced patient experience, and ultimately better patient outcomes.